Anticoagulation in Patients With ICH and Mechanical Valves

Study Questions:

What are the management strategies and associated clinical outcomes associated with intracranial hemorrhage (ICH) in patients with mechanical heart valve (MHV) replacement?


The authors pooled individual patient-level data (n = 2,504) from a German nationwide cohort study of patients who suffered ICH and then identified the patients with a MHV (n = 137). The primary outcome was major hemorrhage complications during hospitalization, analyzed for patients who did and did not restart anticoagulation. The secondary outcomes included thromboembolic complications, timing of anticoagulation re-initiation, and mortality.


Among MVH patients who suffered ICH, 66/137 (48%) restarted anticoagulation with an increased risk of subsequent bleeding complications (26% vs. 6%, p < 0.001) and a trend towards decreased thromboembolic complications (2% vs. 10%, p = 0.06). In time analysis, significant harm (both hemorrhagic and thromboembolic) associated with anticoagulation re-initiation persisted until 6 days following the index ICH, while the risk of ICH alone was elevated until 13 days following the index ICH.


The authors concluded that restarting anticoagulation within 2 weeks of an idex ICH in MHV patients was associated with increased bleeding risk. They also concluded that restarting anticoagulation could be considered as early as 6 days following ICH, when assessing both bleeding and thromboembolic risk.


While limited by a retrospective design, this study provides valuable guidance about the risks and benefits of restarting anticoagulation following an ICH in patients with MHV replacement. Notably, the risk of bleeding complications persists for up to 2 weeks if anticoagulation is re-initiated. However, when considering both bleeding and thromboembolic complications, it is reasonable to restart anticoagulation any time between days 7-14 following an index ICH.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Anticoagulants, Cardiac Surgical Procedures, Cerebral Hemorrhage, Heart, Artificial, Heart Valves, Heart Valve Diseases, Hemorrhage, Intracranial Hemorrhages, Risk Assessment, Secondary Prevention, Thromboembolism, Vascular Diseases

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